<!DOCTYPE html>
<html>
<head>
<meta charset="UTF-8">
<title>申诉单</title>
</head>
<body>
<table border="1" cellspacing="0" width="1000" height="200" align="center">
        <tr>
            <td colspan="5" align="center">申诉单</td>
        </tr>
        <tr>
            <td rowspan="2" align="center">申诉人</td>
            <td>姓名(必须为申诉所涉及号码机主机名)</td>
            <td>&nbsp;&nbsp;&nbsp;&nbsp;<input type="text" name="name" width="200" height="30" ></td>
            <td>联系电话</td>
            <td> &nbsp;&nbsp;&nbsp;&nbsp;<input type="text" name="telephone" width="200" height="30" ></td>
        </tr>
        <tr>
            <td>电子邮件</td>
            <td>&nbsp;&nbsp;&nbsp;&nbsp;<input type="text" width="200" height="30" ></td>
            <td>邮政编码</td>
            <td>&nbsp;&nbsp;&nbsp;&nbsp;<input type="text" width="200" height="30" ></td>
        </tr>
        <tr>
            <td rowspan="2" align="center">被申诉人</td>
            <td>企业名称</td>
            <td colspan="3">
            &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
            <select>
            <option value="1">福州市</option>
            <option value="2">厦门市</option>
            <option value="3">莆田市</option>
            <option value="4">漳州市</option>
            <option value="5">泉州市</option>
            </select>
            &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
            <select>
            <option value="1">晋安区</option>
            <option value="2">鼓楼区</option>
            <option value="3">仓山区</option>
            <option value="4">马尾区</option>
            <option value="5">台江区</option>
            </select>
            &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
            <select>
            <option value="1">电信</option>
            <option value="2">联通</option>
            <option value="3">移动</option>
            </select></td>
        </tr>
        <tr>
            <td>通信地址</td>
            <td colspan="3">&nbsp;&nbsp;&nbsp;&nbsp;<input type="text" size="90" width="800" height="30"></td>
        </tr>
        <tr>
        	<td align="center">是否就申诉事项向被申诉人提出投诉</td>
        	<td colspan="4"><p>
      <label>
        <span id="RadioGroup1_0">
        <input type="radio" name="RadioGroup1" value="单选" id="RadioGroup1_0" />
        是</span></label>
          <span id="RadioGroup1_0">
          <input type="radio" name="RadioGroup1" value="单选" id="RadioGroup1_1" />
          <label>否</label>
          </span>
        <label></label>
<br />
      <br />
    </p></td>
		</tr>
		<tr>
        	<td align="center">被申诉人是否给予处理或答复</td>
        	<td colspan="4"><p>
      <label>
        <span id="RadioGroup2_0">
        <input type="radio" name="RadioGroup2" value="单选" id="RadioGroup2_0" />
        是</span></label>
      <span id="RadioGroup2_0">
      <input type="radio" name="RadioGroup2" value="单选" id="RadioGroup2_1" />
      否</span><br />
      <br />
    </p></td>
		</tr>
		<tr>
			<td rowspan="3" align="center">申诉内容</td>
			<td>申诉要求</td>
			<td colspan="3"><textarea rows="4" cols="70">详见附件用户申诉信</textarea></td>
		</tr>
		<tr>
			<td>申诉事实与理由要求</td>
			<td colspan="3"><textarea rows="4" cols="70">详见附件用户申诉信</textarea></td>
		</tr>
		<tr>
			<td>申诉依据</td>
			<td colspan="3"><textarea rows="4" cols="70">详见附件用户申诉信</textarea></td>
		</tr>
		<tr>
			<td align="center">申诉来源依据</td>
			<td colspan="4">&nbsp;&nbsp;&nbsp;&nbsp;<select>
			<option value="1">传真</option>
			<option value="2">书信</option>
            <option value="3">电话</option>
        </select></td>
		</tr>
		<tr>
			<td align="center">附件上传</td>
			<td colspan="4"><label for="z"></label>
			&nbsp;&nbsp;
            <input type="file" name="z" id="z" />
            &nbsp;&nbsp;&nbsp;&nbsp;
            <input type="submit" name="g" id="g" value="添加附件" /></td>
		</tr>
		<tr>
			<td colspan="5" >&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
  <input type="submit" name="d" id="d" value="提交" /> </td>
		</tr>
    </table>
</body>
</html>

